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APPLICATION FOR REGISTRATIONENRO

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APPLICATION FOR REGISTRATIONENRO Powered By Docstoc
					                                                                                                         GPO Box 4221 Darwin NT 0801
                     HEALTH                                                                                  2nd Floor Harbour View Plaza
                  PROFESSIONS
                                                                                           Cnr McMinn & Bennett Streets Darwin NT 0800
                    LICENSING
                                                                                            Tel: +61 8 8999 4157 Fax: +61 8 8999 4196
                   AUTHORITY
                                                                                                   Email: healthprofessions.ths@nt.gov.au
                                                                                           Website: www.nt.gov.au/health/registrationboards

                     APPLICATION FOR REGISTRATION/ENROLMENT
              Mutual Recognition Act (Commonwealth) 1992, Section 19 Notice
       Trans Tasman Mutual Recognition Act (Commonwealth) 1997, Section 18 Notice
I hereby apply for Registration / Enrolment / Authorisation to practise in a restricted practice area:
        Chiropractor                                            Registered Nurse                            Optometrist
        Dentist                                                                              +              Authorisation as an
                                                                Authorisation as a Midwife
                                                                                                            Optometrist to supply ocular
        Dental Specialist                                       Authorisation as a Nurse                    therapeutics ^
        Dental Hygienist                                        Practitioner                                Osteopath
        Dental Therapist                                        Direct Entry Midwife                        Pharmacist
        Dental Prosthetist                                      Medical Practitioner *                      Physiotherapist
        Enrolled Nurse                                          Occupational Therapist               Psychologist
+
    MIDWIVES - If you are a Registered Nurse who has qualifications to practise in the restricted practise area of midwifery tick both the
    ‘Registered Nurse’ box and the ‘Authorisation as a Midwife’ box. You will need to pay a registration fee of $75 plus the additional fee of $25
    for authorisation to practise in a restricted practice area (total fee $100).
*   MEDICAL PRACTITIONERS - Please note that Medical Practitioners can only apply under the Mutual Recognition Act and are not
    eligible to apply under Trans Tasman Mutual Recognition Act.
^   OPTOMETRISTS – If you are an Optometrist who has qualifications to practise in the restricted practise area of supplying ocular
    therapeutics please tick both the ‘Optometrist’ box and ‘Authorisation to Supply Ocular Therapeutics’ box. You will need to pay a
    registration fee of $35 plus the additional fee of $25 for authorisation to practise in a restricted practice area (total fee $60).

PERSONAL DETAILS
SURNAME:
                                                            Dr         Mr        Mrs       Miss       Ms (please tick as appropriate)

GIVEN NAMES:

FORMER NAMES OR ALIASES:                  (if applicable)

DATE OF BIRTH:                                       /      /                  COUNTRY OF BIRTH:

GENDER:                                       Male          Female (please tick as appropriate)

POSTAL ADDRESS:




BUSINESS ADDRESS:




TELEPHONE NO:                             (bh)                                    (ah)                             (mobile)

FAX NO:                                                                           EMAIL:

QUALIFICATIONS
Educational qualifications (include institution and year of graduation):
                                                                                                                              COMPLETED
           QUALIFICATION                                                       INSTITUTION
                                                                                                                                YEAR




    * PLEASE NOTE DOCUMENTS REQUIRED TO COMPLETE APPLICATION ON PAGE 4*

MR & TTMR Form February 2008                                          1 of 4
    OTHER INFORMATION

    Last practising position was at:

    Dates held:              From:                  /       /               To:               /     /

    Date commencing practise in the Northern Territory:                     /     /

    Intended place of practice in the Northern Territory (if unknown please state):

    Have you ever been registered/enrolled/licensed in the Northern Territory before?             Yes              No

    If yes, what was your registration/enrolment/licence number?

    NOTE: The Health Professions Licensing Authority may from time to time allow organisations to access names and business
    addresses only of practitioners registered in the Northern Territory, if the organisation can demonstrate and satisfy the Board
    that the use of the data will, or has, the potential to contribute to the acquisition of knowledge that may improve the health of the
    community.

    PAYMENT OPTIONS (DO NOT SEND CASH)
    It is recommended that you do not send cash via postal mail. Cash will only be accepted at the Counter.
    Bankcard/Visa/MasterCard are the only Credit Cards accepted.
    Fee of $      is enclosed payable by        Cheque             Money Order
    Card Type                                   Bankcard           Visa                MasterCard
    Card Number


    Expiry
    Date                        /

    Signature                                                          Name (print)


    SCHEDULE OF FEES
    Chiropractor                         $300           valid to 30 Sept    Medical Practitioner               $150      valid to 30 Sept
    Dentist                              $180           valid to 30 Sept    Occupational Therapist              $40      valid to 30 Sept
    Dental Specialist                    $180           valid to 30 Sept    Optometrist                         $35      valid to 30 Sept
    Dental Hygienist                      $30           valid to 30 Sept    Osteopath                          $300      valid to 30 Sept
    Dental Therapist                      $30           valid to 30 Sept    Pharmacist                          $35      valid to 30 Sept
    Dental Prosthetist                    $30           valid to 30 Sept    Physiotherapist                    $70       valid to 30 Sept
    Enrolled Nurse                        $75           valid to 30 Sept    Psychologist                        $40      valid to 30 Sept
    Registered Nurse                      $75           valid to 30 Sept    Authorisation to practise in
                                                                            a restricted practice area - add    $25      valid to 30 Sept
    Direct Entry Midwife                  $75           valid to 30 Sept




IMPORTANT - Please read the following before completing the rest of the form:
•      If you are not able to answer ‘true’ to statements 3, 4, 5 and 6 in the Statutory Declaration you may not
       be eligible to lodge a notice under section 19 of the Mutual Recognition Act or section 18 of the Trans
       Tasman Mutual Recognition Act and should enquire with the Board as to how you should make an
       application for registration.
•      If you are licensed with conditions please advise how you intend to satisfy these conditions in the
       Northern Territory.
•      Incomplete notices of application, including omission of payment of the appropriate fee and required
       documents, will not be accepted by the Board resulting in deferment of the right to practise.
•      Statements or information, which are materially false or misleading, may result in postponement or
       refusal of registration.


    MR & TTMR Form February 2008                                   2 of 4
STATUTORY DECLARATION
                                                  COMMONWEALTH OF AUSTRALIA
                                                      Statutory Declaration


NOTE:            All questions and statements must be completed (please tick appropriate box where applicable)


I,
                               (Given Name)                                                           (Surname)
 of
                                                                     (Address)
hereby seek registration/enrolment/licence/authorisation to practise in accordance with the mutual recognition principle and in
support of my application do solemnly and sincerely declare as follows:

     1.   I am currently registered/enrolled/licensed/authorised to practise in the following State/Territory/Country, which is the
          State/Territory/Country on which I base my application for registration.


     2.   I also currently hold or have held registration/enrolment/licence/authorisation to practise in the following
          States/Territories/Countries:




     3.   I consent to the Health Professions Licensing Authority of the Northern Territory making enquiries of
          and the exchange of information with the authorities of any State/Territory/Country regarding my
          activities as a health practitioner.                                                                             Yes     No
     4.   I am not the subject of disciplinary proceedings in any State/Territory/Country or any preliminary
          investigations or action that might lead to disciplinary proceedings in relation to my practise as a
          health practitioner.                                                                                           True    False
     5.   My registration/enrolment/licence/authorisation has not been cancelled nor is it currently suspended
          as a result of disciplinary action in any State/Territory/Country.                                             True    False
     6.   I am not otherwise personally prohibited from carrying out practise as a health practitioner as a
          result of criminal, civil or disciplinary proceedings in any State/Territory/Country.                          True    False
     7.   My registration in another State/Territory/Country is not subject to any other special conditions,
          limitations or restrictions.                                                                                   True    False
     8.   I am not suffering from a mental or physical disability, which would prevent me practising efficiently.        True    False
     9.   I have not practised unlicensed in the Northern Territory.                                                     True    False
     If “False” to any of the above, please provide full details on an attached signed sheet.
And I make this solemn declaration by virtue of the Statutory Declarations Act 1959 of the Commonwealth and subject to the
penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believing the statements
contained in this declaration to be true in every particular.

Signature of person making declaration:

Declared at:                                              on the:                           day of:                              20
before me,

             Signature of person witnessing declaration:
                               Name of witness (printed):
                   Title of witness (printed), if applicable:
               Address or telephone number of witness:


The Statutory Declaration may be signed by a Justice of the Peace, Solicitor or by a person authorised within your State/
Territory/Country to witness statutory declarations/affidavits. Only if you are physically located in the Northern Territory, then the
declaration may be witnessed before any person who has attained the age of 18 (eighteen) years.



MR & TTMR Form February 2008                                    3 of 4
         DOCUMENTS AND OTHER REQUIREMENTS FOR
                     REGISTRATION

The following documents MUST be provided with this application form. Photocopies
will only be accepted if they have been certified to be a true copy by: a Justice of
the Peace, Commissioner for Oaths, Police Officer, Solicitor, Bank Manager, Postal
Manager, Pharmacist, Australian Defence Force Commissioned Officer, NCO or
Warrant Officer; or the originals sighted by an authorised Health Professions
Licensing Authority staff member. It is not recommended that you send originals by
post. Certified copies will be retained on file.

         Evidence of current registration/enrolment in Australian or New Zealand
         (Annual Practising Certificate or Certificate of Registration issued within the last
         12 months).

         Proof of Identity
         (Provide one of the following: Drivers Licence; Passport; Birth Certificate; or
         Statutory Declaration attesting to the applicant’s identity or other form of official
         identification).

         Evidence of Name Change (Marriage Certificate, Divorce Decree or Deed Poll)

         An application and registration fee in Australian dollars
         (see Payment Options and Schedule of Fees sections of this form).

         All parts of application form completed in full.

TO ASSIST IN THE TIMELY PROCESSING OF YOUR APPLICATION, PLEASE
ENSURE THAT YOU HAVE ATTACHED THE ABOVE MENTIONED CERTIFIED
DOCUMENTS TO YOUR COMPLETED APPLICATION FORM.


On completion of your application form please send your application and
supporting documentation by one of the following methods to Health
Professions Licensing Authority:

Post:                  Health Professions Licensing Authority
                       GPO Box 4221
                       Darwin NT 0801
Hand Deliver:          2nd Floor Harbour View Plaza
                       Cnr McMinn & Bennett Streets
                       Darwin NT 0800
Facsimile:             +61 8 8999 4196


If you have any queries regarding your application please contact us on:
Phone:                 +61 8 8999 4157
Email:                 healthprofessions.ths@nt.gov.au



MR & TTMR Form February 2008                   4 of 4

				
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